Antithrombotic Therapy in Children: Central Venous Lines

Clinical Features: Despite the protective effects of age, increasing numbers of children are developing DVT/PE as secondary complications of their underlying disorders. In contrast to adults, in whom DVT/PE is idiopathic in 40% of patients, only 5% of DVT/PEs are idiopathic in children. Ninety-five percent of DVT/PE cases in pediatric patients are problems secondary to serious diseases, such as prematurity, cancer, trauma/surgery, congenital heart disease, and systemic lupus erythematosus. Congenital prethrombotic disorders alone account for <10% of DVT/PE cases in children. The frequency of congenital prethrombotic disorders in children with secondary DVT is uncertain, but it may be substantial. The ages of greatest risk for DVT/PE are infants of age <1 year and teenagers. DVT in the lower extremities is the most frequent non-CVL thrombotic complication in children. The clinical presentations and treatment of DVT/PE are similar to those in the adult.
Central Venous Lines: Forty percent of DVT in children and over 80% in newborns occur in the upper venous system secondary to the use of CVLs. CVLs are placed for short-term intensive care or for long-term supportive care in children requiring total parenteral nutrition or therapy for cancer. Flovent inhaler more CVL-related DVTs are not trivial, as they require repeat anesthesia for replacement; provide a source for PE; cause superior vena cava syndrome, chylothorax, and eventual destruction of the upper venous system; and contribute to postphlebitic syndrome in the upper extremities. The long-term consequences of extensive CVL-related DVT are not known at this time. However, the available information strongly suggests that CVL-related DVTs are not benign.
The incidence of CVL-related thrombosis reported in the literature varies, reflecting different underlying disorders, diagnostic tests, and indexes of suspicion. For example, the incidence of CVL-related thrombosis in children receiving long-term total parenteral nutrition varies from 1%, based on clinical diagnosis,to 35%, based on ventilation perfusion scans or echocardiography, to 75%, based on venography. In many patient populations, the incidence is not accurately known. This information is important in identifying populations of children in whom prophylactic antithrombotic therapy should be tested in clinical trials.